The Effect of Primary Aldosteronism on Carotid Artery Texture in Ultrasound Images

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. Early diagnoses of PA are essential to avoid the long-term negative effects of elevated aldosterone concentration on the cardiovascular and renal system. In this work, we study the texture of the carotid artery vessel wall from longitudinal ultrasound images in order to automatically distinguish between PA and essential hypertension (EH). The texture is characterized using 140 Haralick and 10 wavelet features evaluated in a region of interest in the vessel wall, followed by the XGBoost classifier. Carotid ultrasound studies were carried out on 33 patients aged 42-72 years with PA, 52 patients with EH, and 33 normotensive controls. For the most clinically relevant task of distinguishing PA and EH classes, we achieved a classification accuracy of 73% as assessed by a leave-one-out procedure. This result is promising even compared to the 57% prediction accuracy using clinical characteristics alone or 63% accuracy using a combination of clinical characteristics and intima-media thickness (IMT) parameters. If the accuracy is improved and the method incorporated into standard clinical procedures, this could eventually lead to an improvement in the early diagnosis of PA and consequently improve the clinical outcome for these patients in future.

Stent Selection for Primary Angioplasty and Outcomes in the Era of Potent Antiplatelets. Data from the Multicenter Randomized Prague-18 Trial

Drug-eluting stents (DES) are the recommended stents for primary percutaneous coronary intervention (PCI). This study aimed to determine why interventional cardiologists used non-DES and how it influenced patient prognoses. The efficacy and safety outcomes of the different stents were also compared in patients treated with either prasugrel or ticagrelor. Of the PRAGUE-18 study patients, 749 (67.4%) were treated with DES, 296 (26.6%) with bare-metal stents (BMS), and 66 (5.9%) with bioabsorbable vascular scaffold/stents (BVS) between 2013 and 2016. Cardiogenic shock at presentation, left main coronary artery disease, especially as the culprit lesion, and right coronary artery stenosis were the reasons for selecting a BMS. The incidence of the primary composite net-clinical endpoint (EP) (death, nonfatal myocardial infarction, stroke, serious bleeding, or revascularization) at seven days was 2.5% vs. 6.3% and 3.0% in the DES, vs. with BMS and BVS, respectively (HR 2.7; 95% CI 1.419–5.15, p = 0.002 for BMS vs. DES and 1.25 (0.29–5.39) p = 0.76 for BVS vs. DES). Patients with BMS were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, p = 0.045) and at one year (HR 2.1; 95% CI 1.19–3.69; p = 0.01); they also had a higher composite of cardiac death, reinfarction, and stroke (HR 1.66; 95% CI 1.0–2.74; p = 0.047) at one year. BMS were associated with a significantly higher rate of primary EP whether treated with prasugrel or ticagrelor. In conclusion, patients with the highest initial risk profile were preferably treated with BMS over BVS. BMS were associated with a significantly higher rate of cardiovascular events whether treated with prasugrel or ticagrelor.

Clinical outcomes with drug-eluting stents, bare-metal stents, and bioresorbable scaffolds implanted in patients with AMI treated with primary PCI. Data from the Prague-18 trial

Background

Drug-eluting stents (DESs) are the recommended choice of stents for primary PCI.

Purpose/Methods

The study aimed to determine why interventional cardiologists used non-DESs and how they had influenced the patient prognosis. The efficacy and safety outcomes of the different stents were also compared in treated with either prasugrel or ticagrelor.

Results

Of the PRAGUE 18 study patients, 749 (67.4%) were treated with DESs, 296 (26.6%) with BMS, and 66 (5.9%) with BVS. Cardiogenic shock at presentation and the left main disease, especially as culprit lesion, and right coronary artery stenosis were the reasons for BMS selection.

The incidence of the primary net-clinical EP (CV death, nonfatal MI, stroke, major bleeding, or revascularization) at 7 days was 2.6% vs. 6.5%, and 3.0% in the DESs, BMSs, and BVSs, respectively (HR 2.7; 95% CI 1.419–5.15, P=0.002 for BMS vs. DES and 1.25 (0.29–5.39) for BVS vs. DES, P=0.76). Patients with BMSs were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, P=0.045), and at one year (HR 2.1; 95% CI 1.19–3.69; P=0.01); they also had higher composite of cardiac death, re-MI and stroke (HR 1.66; 95% CI 1.0–2.74; P=0.047) at one year. BMSs were associated with significantly higher rate of primary EPs either treated with prasugrel or ticagrelor.

Conclusion

Patients with the highest risk profile were preferably treated with BMS the contrary to BVS. BMSs were associated with a significantly higher rate of cardiovascular events either treated with prasugrel or ticagrelor.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Charles University Cardiovascular Research Program P-35 and Q-38, Charles University, Czech Republic

The prognostic significance of periprocedural infarction in the era of potent antithrombotic therapy. The PRAGUE-18 substudy

BACKGROUND

The prognostic significance of periprocedural myocardial infarction (MI) remains controversial.

METHODS AND RESULTS

The study aims to investigate the incidence of periprocedural MI in the era of high sensitivity diagnostic markers and intense antithrombotics, and its impact on early outcomes of patients with acute MI treated with primary angioplasty (pPCI). Data from the PRAGUE-18 (prasugrel versus ticagrelor in pPCI) study were analyzed. The primary net-clinical endpoint (EP) included death, spontaneous MI, stroke, severe bleeding, and revascularization at day 7. The key secondary efficacy EP included cardiovascular death, spontaneous MI, and stroke within 30 days. The incidence of peri-pPCI MI was 2.3% (N = 28) in 1230 study patients. The net-clinical EP occurred in 10.7% of patients with, and in 3.6% of patients without, peri-pPCI MI (HR 2.92; 95% CI 0.91-9.38; P = 0.059). The key efficacy EP was 10.7% and 3.2%, respectively (HR 3.44; 95% CI 1.06-11.13; P = 0.028). Patients with periprocedural MI were at a higher risk of spontaneous MI (HR 6.19; 95% CI 1.41-27.24; P = 0.006) and stent thrombosis (HR 10.77; 95% CI 2.29-50.70; P = 0.003) within 30 days. Age, hyperlipidemia, multi-vessel disease, post-procedural TIMI <3, pPCI on circumflex coronary artery, and periprocedural GP IIb/IIIa inhibitor were independent predictors of peri-pPCI MI.

CONCLUSIONS

In the era of intense antithrombotic therapy, the occurrence of peri-pPCI MI is despite highly sensitive diagnostic markers a rare complication, and is associated with an increased risk of early reinfarction and stent thrombosis.

Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention

Background

Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI).

Purpose

Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI.

Method

The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year.

Results

Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow &lt;2 before PCI (p=0.029), TIMI flow &lt;3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B &lt;30 min was achieved in 70% of patients, only 5.3% had interval &gt;90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age &gt;70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP &lt;100 mmHG and HR &gt;100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. &gt;6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028).

Conclusion

The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow &lt;3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction.

Funding Acknowledgement

Type of funding source: None

P1727Prognosis predictors of patients with initial cardiogenic shock complicated acute myocardial infarction treated with primary angioplasty and intense antiplatelet therapy. PRAGUE-18 shock substudy

Background

Early reperfusion of the infarct related artery is the only treatment improving prognosis of patients with initial cardiogenic shock (CGS) complicated acute myocardial infarction (AMI) (Killip class IV at admission).

Purpose

The analysis focused on subgroup of patients with initial CGS randomized into the multicenter PRAGUE-18 study (prasugrel vs. ticagrelor in primary PCI).

Methods

In the PRAGUE-18 study, patients with acute myocardial infarction (AMI) (n=1230) treated with primary percutaneous coronary intervention (pPCI) were immediately randomized to prasugrel or ticagrelor with intended treatment duration of 12 months. 53.6% (n=659) switched to clopidogrel after discharge. Major ischemic and bleeding events were followed throughout the entire study period. Beside standard laboratory tests, efficacy of ticagrelor and prasugrel was measured by flow cytometric VASP evaluation in patients selected for a laboratory sub-study (n=218). Acute heart failure (KILLIP >1) was present in 11.8%, and 46 patients (3.7%) randomized to the study were in CGS.

Results

Patients with CGS were older [66.7 (48,3; 83,3) years] than those without CGS (KILLIP <4), and had the highest prevalence of bundle brunch block on the initial ECG (RBBB in 6.5%, LBBB in 8.7%, p=0.003 for difference in bundle brunch blocks). Time delay to hospital admission [1,7 (0,4; 36,0) hs] was significantly shorter than in patients KILLIP <4 [2,8 (0,8; 28,3hs; p=0.003]. Significantly more CGS patients had history of previous MI (19.6% vs 7.9%, p=0.011) and bypass graft surgery (6.5% vs 1.5%, p=0.041). 67.4% of CGS patients had multivessel disease and in 17.4% of these patients primary PCI was evaluated as suboptimal result or procedural failure (compared to 4.3% in patients without shock, p<0.001).

No difference was observed in clinical (primary and secondary endpoints, p=0.564) or laboratory efficacy between prasugrel and ticagrelor treated patients with CGS (p=0.800 for VASP index difference between prasugrel and ticagrelor 20±4 hs after loading doses). We did not find any difference in initial platelet activation (VASP index before P2Y12 inhibitors administration) in patients without acute heart failure (KILLIP I) [83.2 (54.1–94.2) %] and with KILLIP > I [82.5 (65.7–96.9), p=0.999], and this was also confirmed for the difference between KILLIP I and KILLIP IV patients (p=0.416).

Conclusion

Results of the present analysis and defined predictors of mortality showed that prognosis of patients with initial cardiogenic complicated AMI treated with pPCI cannot be influenced by more potent platelet inhibition (than in AMI patients without CGS). Furthermore, the concluding evidence underscored adherence to the current guidelines' recommendation of the earliest possible reperfusion of infarct related artery as well as administration of prasugrel or ticagrelor.

Long-Term Effect of Adrenalectomy on Cardiovascular Remodeling in Patients With Pheochromocytoma

CONTEXT

Catecholamines may contribute to the accumulation of collagen fibers and extracellular matrix in the arterial and myocardial wall due to various mechanisms. Reversibility of this process has not been studied on both structures simultaneously.

OBJECTIVE

To clarify the long-term effect of excess normalization of catecholamines on carotid and myocardial wall changes in patients with pheochromocytoma or functional paraganglioma (PHEO) after tumor removal.

DESIGN, SETTINGS, AND PATIENTS

Carotid intima-media thickness (IMT) and the left ventricular (LV) mass index were studied in 50 patients with PHEO before tumor removal and 5 years after tumor removal, and in 50 blood pressure- and age-matched essential hypertensive patients before follow-up and after 5 years of follow-up.

MAIN OUTCOME MEASURES

Common carotid artery (CCA)-IMT and LV mass indexed to lean body mass (LBM).

RESULTS

Elimination of catecholamine excess in the PHEO group resulted in a significant decrease in CCA-IMT and LV mass index from 0.86 ± 0.17 to 0.83 ± 0.18 mm (P < 0.05) and from 3.2 ± 0.9 to 2.9 ± 0.9 g/LBM (P < 0.001), respectively. In contrast, CCA-IMT and LV mass index increased significantly from 0.78 ± 0.14 to 0.81 ± 0.15 mm (P < 0.05) and from 3.1 ± 0.7 to 3.2 ± 0.6 g/LBM (P < 0.05), respectively, in patients with essential hypertension.

CONCLUSION

In patients with PHEO, carotid IMT and LV mass index can significantly regress after tumor removal, in contrast to the impairment of these parameters in essential hypertensive patients during the same long-term period.

Prasugrel Versus Ticagrelor in Patients With Acute Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Multicenter Randomized PRAGUE-18 Study

BACKGROUND

No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y₁₂ inhibitors were first demonstrated relative to clopidogrel.

METHODS

This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017.

RESULTS

The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864).

CONCLUSIONS

This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

Fibroblast growth factor 23 accelerates phosphate-induced vascular calcification in the absence of Klotho deficiency

Fibroblast growth factor 23 (FGF23) is a phosphate-regulating hormone that acts primarily on the kidney and parathyroid. With declining kidney function there is an increase in circulating FGF23 levels, which is associated with vascular calcification and mortality in chronic kidney disease. Whether FGF23 exerts direct effects on vasculature is unclear. We evaluated the expression of Klotho and FGF receptors in rat aortic rings and rat aorta vascular smooth muscle cells maintained in culture by reverse transcription-PCR, western blotting, and immunostaining. Signaling pathways underlying FGF23 effects were assessed by western blotting, and effects of FGF23 on osteogenic markers and phosphate transporters were assessed by real-time reverse transcription-PCR. We detected Klotho and FGFR1 in total aorta but not in vascular smooth muscle cells. FGF23 augmented phosphate-induced vascular calcification in the aortic rings from uremic rats and dose dependently increased ERK1/2 phosphorylation in Klotho-overexpressing but not naive vascular smooth muscle cells. FGF23-induced ERK1/2 phosphorylation was inhibited by SU5402 (FGFR1 inhibitor) and U0126 (MEK inhibitor). FGF23 enhanced phosphate-induced calcification in Klotho-overexpressing vascular smooth muscle cells and increased osteoblastic marker expression, which was inhibited by U0126. In contrast, phosphate transporter expression was not affected by phosphate or FGF23. Thus, FGF23 enhances phosphate-induced vascular calcification by promoting osteoblastic differentiation involving the ERK1/2 pathway.